* = Required fields

Choose which Global Medevac enrollment option is best for you: *
Region 2 Plan: Individual Monthly Preferred Hospital • $35/moRegion 2 Plan: Family Monthly Preferred Hospital • $55/moRegion 2 Plan: Individual Yearly Preferred Hospital • $410/yrRegion 2 Plan: Family Yearly Preferred Hospital • $645/yrRegion 1 Plan: Individual Monthly Preferred Hospital • $28/moRegion 1 Plan: Family Monthly Preferred Hospital • $42/moRegion 1 Plan: Individual Yearly Preferred Hospital • $325/yrRegion 1 Plan: Family Yearly Preferred Hospital • $495/yrFlorida U.S. Plan: Individual Monthly Preferred Hospital • $20/moFlorida U.S. Plan: Family Monthly Preferred Hospital • $30/moFlorida U.S. Plan: Individual Yearly Preferred Hospital • $230/yrFlorida U.S. Plan: Family Yearly Preferred Hospital • $350/yrStandard Puerto Rico Plan: Individual Monthly Preferred Hospital • $10/moStandard Puerto Rico Plan: Family Monthly Preferred Hospital • $20/moStandard Puerto Rico Plan: Individual Yearly Preferred Hospital • $110/yrStandard Puerto Rico Plan: Family Yearly Preferred Hospital • $230/yr

Primary Member Information:

Note: Preexisting conditions are covered after 90-days

First Name *

Middle Name

Last Name *

Birthdate *

Age *

Your Email *

Mobile Phone Number *

Member's Spouse Information:

Note: Preexisting conditions are covered after 90-days

First Name

Middle Name

Last Name

Birthdate

Age

Spouse Email

Mobile Phone

Dependent's Information:

Note: Preexisting conditions are covered after 90-days

First Name

Middle Name

Last Name

Birthdate

Age

Second Dependent's Information:

Note: Preexisting conditions are covered after 90-days

First Name

Middle Name

Last Name

Birthdate

Age

Home Benefits Address:

Street Address *

Island *

State *

Zip *

Mailing Address (IF DIFFERENT FROM HOME BENEFITS ADDRESS):

Street Address

Island

State

Zip

Agent Information:

Agent Name

Agent Number

Preferred Payment Method: *

Note: a Global Medevac agent will reach out to you to process your payment

Annual Credit/Debit Card PaymentEFT/ACH Payment

REFERRAL INFORMATION:

(help someone else gain the ultimate peace of mind)

First Name

Last Name

Age

Email

Mobile Phone Number

Yes, I would like to receive Global Medevac's monthly life-saving news and information. (Please be sure to add Global Medevac to your email address book to avoid our information getting lost in your spam or junk email box)